Insulin Options Flashcards
What chemical was added to insulin in 1950 that is still used today to increase the half life of insulin?
Protamine
Purified pork insulin 7 then recombinant human insulin virtually eliminated what diabetic complication?
Insulin allergy & immune-mediated lipoatrophy
What are older insulins more commonly associated with?
hypoglycemia
Weight gain while on insulin is due to what 4 things?
- anabolic effects of insulin
- increased appetite
- defensive eating from hypoglycemia
- Caloric retention r/t decreased glycosuria
Insulin is a very common offender in causing ER visits due to hypoglycemia. What is a common reason for this?
Inability to draw up an accurate dose
Prandial insulins (Bolus)
Fast acting: Regular
Faster acting: Lispro, aspart, glulisine, human (inhaled)
Basal insulins
Intermediate acting: NPH
Long acting: Glargine, determir, degludec
Biphasic combination that is commonly used
70% NPH/30% regular
What is a pearl about insulin metabolism
Insulin is broken down in the kidney
If CKD, decrease dose to compensate
Prandial Insulin MOA
-Act on specific membrane-bound receptors on target tissues to regulate metabolism of carbohydrates, protein, and fats
***Also increases cellular permeability to several ions (K, Mg, phos)
Regular insulin pearls
- Cheap
- Good for DM gastroparesis (later onset when gastric emptying occurs)
- less physiologic and causes more hypoglycemia
Take 30 min before meal
“Faster” insulin pearls
- superior to regular insulin in reducing postprandial hyperglycemia
- More rapid pharmacodynamics make post-absorptive hypoglycemia less common than in regular insulin
- $$$$ (expensive)
Take right before first bite
Faster insulin and exercise
Patients who exercise 1–3 hrs after a meal require dose reduction
Inhaled insulin (human)
- expensive
- Not used much
- Pax daddy fatty bong rips
Prandial insulin interactions/ADRs
- All agents have longer half life with CKD
- Hypoglycemia
- weight gain
NPH pearls
- cheap and familiarity
- Less physiologic, causes more hypoglycemia (nocturnal)
- Erratic pharmacokinetics
Glargine: onset, peak, duration, meal timing
- Onset: 1 hr
- Peak: none
- Duration: 24 hrs
- Meal timing: take at same time of the day
Detemir: onset, peak, duration, meal timing
- Onset: 1-2 hrs (dose dependent)
- Peak: flat
- Duration: dose dependent, low = 12hrs, high =20-24hrs
- Meal timing: qday = PM meal or hs, BID 12 hrs pAM dose
Degludec: onset, peak, duration, meal timing
- Onset: 30-90min
- Peak: none
- Duration: 42 hrs
- Meal timing: no requirements
Advantages of Basal Insulin Analogues
- Long duration of actions (qday)
- No peak
- Less nocturnal hypoglycemia
Disadvantages of Basal Insulin Analogues
- Generally cannot be mixed with other insulins*
- Slower onset of action
- If OD, prolonged risk of hypoglycemia
CI with Basal Insulin Analogues
All agents have a longer half life with CKD*
ADRs of Basal Insulin Analogues
Hypoglycemia, weight gain
Biphasic Insulins (include onset, peak, duration, admin, timing, color)
70% NPH, 30% regular
- Onset: 30 to 60min
- Peak: 2-12 hrs
- Duration: effective 10-15 hrs
- Admin: SC bid
- Meal timing: 30 min before meal
- Color cloudy
Clinical use of biphasic insulins
- For patient unwilling to do >2 injections per day*
- Minimal use overall (duration of action longer in CKD, less flexibility, $$$)
Where does insulin rank in comparison to metformin/other oral drugs? Is it first line, second line, etc?
Consider insulin second line after metformin IF A1c is >/= 9%, especially if asymptomatic
Rundown of initiating insulin therapy - where do you start, and what are the next three options?
-Start with longer-acting, “basal” insulin once daily
THEN
-Option 1: add GLP-1 agonist, can help limit weight gain due to insulin
-Option 2: add “prandial” insulin at largest meal
-Option 3: switch to premixed insulin BID (less cost)
Pearl about sliding scale insulin, w
This chases glucose, doesn’t control it
Sliding scale insulin options
- Option 1: basal insulin
- Option 2: basal plus short/rapid acting
- Option 3: basal bolus (basal qday or BID plus short-acting before each meal)
Options for pregnancy
- Diet/nutritional counseling and exercise
- Oral agents (metformin = B)
- Insulin = gold standard/drug of choice if not controlled with diet/exercise (NPH and regular have the most safety data)
